24054APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
ild (ng Add ss:
BuSILO
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PERMIT NQ, 4 0 5 4
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APPLECATToN SUBMITTALA
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CITY OF CUPER-I NO -BUILDING DIVISION
APPLICATION / PERMIT
C as n aNane: .
LicNo
BUILDING-ELECTRICALPLUMBING-MELHANICAL
CATEGORY
CONTROL M
hitectlEgineer. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE s/
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aRirenthat l am licensed under provisions of Chapter9(commenc-
IngwlNScct1on7000)of Dwision3of he B�uq(�ossayd PJofessionsCodg and my,
license sin f ddfeat. qL \ ) / /_
APPUANCESRESIDENTIAL
JOB DFSCRI'TfON
PANELSn
LI Clz Lic.p llW KJ
Dal ContractorUP
TO 2DO AMPS
201-10D)AMPS
RCHITE
[ derstand my plans shall be used as public records.
OVER IWO AMPS
SQ. FT. FLOOR AREA VSQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNEReBUILDER DECLARATION
Thereby aflnnthatIn 7exemptfro ossa and Contractor'License Taw fort he
following reason. (Semon 7031.5, Business and Pro prove, Code: Any city it
cnuPUTEF
ntywhirh requires ismareomvtequireser, applicantforsuch ish,or repair
also sed pursuant t the po vislomofpermit e
any awrnare statempriortoent thathe
(Ile a signed statement Nat he (Chapter llrensed pursuant it the provisions of the
Con3fthe License Lawfistah9(rommentlngwith xciaScettotthamfofand Mvi-
konProfessionCode)inlethef exempt therefrom and
the the alleged
the basis for the alleged exemption. Any violation of Section nm by any
applicant (ora permit eubjectathe applicant to a tivll penalty°(not more than
five hundred dollars (5500).
MI, as owner of the property, or my employees with wages as their sole
\j
I
fi �]
IM
`^ /�
/�
SPECIALCIRCUIT/M1SC
_
' P.MEFLi9OR POLE INSI.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESHXTURES
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, willdothe work and Nestrocture is neat intended or offered for
sale (&c. 7004, Business and Professions Code: The Contractor's Limme Law
TOTAL; I
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
does not apply to an owner of property who builds or improves thereon, and
doessuch work himself orthmugh his own employees, provided that such
improvements are not buendeddrofferedforsale. If, however, the building or
improvement iseoldwithin onayearofcomple ion,theowner-bullderwiil have
N,gj,uden of proving that he did na bund or improve for purpose ofvle).
LI L as owner of the property, am exclusively contracting with licensed
contractors to construct the proyet (Sec. 7044, Business and Professions Code:
OCC.GROUIs
RFS. UNITS
F(pp ,OHNE
nPN
The Contractofa Llmrae Law does out apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p;oje s, with a
,J(actor(s)hoenud pursuant to the Contractors License Law.
LJ I am exempt under Sec. B k P C for this reason
ALM -DRAIN kVENT- WATER (FA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OuTSIDF FEE'S
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to se Firsare, w a
DRAINS FLOOR ROOF, AREA, CONI).
SWA Y Y N
RECER'r M
r�
pIX1URF5-('FR` i I,� ;t. /
i TAX Y_ N
certiflcateof Work m'ComNmationlmurany'c ggqVVKtf them°(
3800. LaabCJ^�% �,ll\/O ��p�JJ PY (
IJ Llalir" A —L•
PolCom
RECESI'f M
GAS EA SYSTEM lI 0[TILEfS I i.)
-
PARK Y N
RECEB'f M
any I
Certified copy isfi rebyth the city
�rtl(led copy V filed with the tlty Ivpectlon division.
GAS EA. SYSTEM -0 �4 (FA) ` " _
CREASE/INDUSIRL WAURy''gRC TOR
BUILDING DI VISION FEES
-RL,ANCHEGK FEE
GRFASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ffhissectioneced not be completed ifthepernet isforons hundreddollars
(5100)drfyttu
Imnot employ an persmamm�f tmnner so as toowhich this pesubpebooed,
I dull not empty any person f any manner at v to become eub)m to the
Worken Compensation laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should became subject to the Workers Compensation provisions of the Labor
Code, you must fort hwith comply with such provisions or this Permit shall be
deemed revoked.
PAID
Date Rem( t#
SEWER -SANITARY -STORM EA. 2WE'.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB._SQ.FT.
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I herebyffi
arm that there i a construction tction lending agency for the perform,ELECTRIC
Lend the work for which this permit is Issued (Sec. 3097, Cie. C.)
Lendererb Nada
Len codiAddress
have ready with all ll dtlon d c staunty cardia above informd gatert on laws
is Irmd. Ify agratlee
Iagreng mmplywithandhered countyordinancesand state laws
ml
relating to Tiding mnatatllon, and hereby authorize representauvesofthis
representative
city toe er Pon eabove'rooEoad property, for Inspection purposes.
(We a aa e, Indemofy an d keep harMees the City of Cupertino
again Ub tl ,ju ere, sea which may In nywayaccrue
agave said In s gra Ing of this P3qputj I
TOTAL:
SEISMIC FEE
FEE
QTY. MECHANICAL PER FEE
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT RO 10,000 CFM)
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL:
AIR HA NDUNG UNIT (OVER I Q000 CFM)
CONSTRUCTION TAX
2�3 1q7
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
UMTOO 100,000 BTU) Cl
Will the applicant car future building occupant store or handle hazardousHEATING
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Iiealth and Safety Code Section 25532(a)2
M Yes M No
Date ReceI
HEATING UNIT (OVER 100,000 BTU)
TOTh:
Will the applicant or futum Wilding occupant use equipment ordevices
which emit harardous air mntnminanta as defined by the Bay Area Air
Qua lily Management Dist rict7
Yes n No
have read the h rdous materials requirements under Chapter 6.95 of
the California Health A Safety Code, Section 25505, 25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Ocen pa my.
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
II
L ��
DEC 1 199
611i Ur (aUrchI INU
N
ISSUED BY.
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER10e,OOD BM
NEW RESIDENTIAL MECH. $Q.FF.
Owner or atath agcgent Dte a —
TOTAL: /'
OFFICE COPY